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Pregnancy

Dr Louise Kenny answers questions from GP Dr Dinah Roy, while overleaf experts give an update on neonatal screening

Dr Louise Kenny answers questions from GP Dr Dinah Roy, while overleaf experts give an update on neonatal screening

1. I've heard there is a link between women taking paracetamol in late pregnancy and an increased risk of having a child who goes on to develop asthma. Is this true?

Two large epidemiology studies (both on the Avon Longitudinal Study of Parents and Children cohort of more than 14,000 pregnancies) have suggested a positive association between paracetamol use in pregnancy and an increased risk of wheeze in offspring aged three years and subsequent asthma, wheezing and elevated serum IgE antibodies in offspring aged six. This risk is apparently greatest for women who take paracetamol on most days in late pregnancy (defined as 20-32 weeks). However, occasional use of paracetamol does not appear to be associated with an increased risk of asthma.

2. Does aspirin prevent pre-eclampsia?

It now seems clear that antiplatelet therapy, in particular low-dose (<75mg) aspirin, reduces the risk of pre-eclampsia by around 15 per cent for women at both low and high risk. There appears to be a similar reduction in the risk of perinatal death. Aspirin should therefore be considered, particularly for women at high risk of the disease.

3. Can pre-eclampsia be detected or screened for in the community?

Currently, there is no single screening test specific enough to be clinically useful. The Action on Pre-eclampsia PRECOG guideline (www.apec.org.uk/precog.htm) describes a simple assessment that can be conducted at booking, to identify women who are more likely to develop pre-eclampsia. It also details factors that require referral for specialist input early in pregnancy. This document also suggests a systematic community assessment for indications of onset of pre-eclampsia from 20 weeks with the frequency of assessment determined by the likelihood of developing pre-eclampsia.

4. How should you treat chlamydia during pregnancy?

Chlamydia infection in pregnancy is associated with a risk of neonatal infection and it may result in neonatal conjunctivitis and/or pneumonia. Doxycycline, commonly prescribed for chlamydia, should be avoided in pregnancy because of the permanent effect of tetracyclines on dental enamel.Consequently the treatment of choice for chlamydia infection in pregnancy is erythromycin 500mg orally qds for 10 days.

Patient compliance is often problematic. The oral administration of 1g of azithromycin has a similar or higher efficacy and similar or fewer side-effects than the alternative week-long regimens, and has become the drug of choice. Although azithromycin is still not officially licensed for chlamydia in pregnancy, clinical experience and research data suggest azithromycin is effective and safe for the fetus, and the drug is listed as an alternative regimen for pregnant women in the Centers for Disease Control STD treatment guidelines.

5. Are midwife-led delivery units safe?

A recent Cochrane review of home-like versus conventional institutional settings for birth included six trials of 8,677 women. Home-like setting significantly increased the likelihood of a spontaneous vaginal birth and satisfaction with intrapartum care. But between 29 and 67 per cent of women allocated to home-like settings were transferred to standard care before or during labour. Furthermore, there was a trend towards higher perinatal mortality in the home-like setting, but this did not achieve statistical significance.

It would seem appropriate to advise women that home-like settings in close proximity to consultant-led units confer modest benefits without a statistically significant increase in perinatal mortality for low risk pregnancies. This meta-analysis did not include any data from standalone midwifery-led units where geographical isolation may mean the rare occurrence of an obstetric emergency may have devastating consequences that may have been avoided in a conventional setting.

6. How useful is information from organisations like Dr Foster in helping women decide on their preferred place of birth ­ particularly if considering a home birth?

Dr Foster is a valuable resource and provides basic statistics and information on facilities and waiting times as well as individual consultants' special interests and skills. The options for where to give birth are best discussed with a health professional. Occasionally women have risk factors that they are unaware of and that make them unsuitable for low-risk antenatal care.

7. What is the best screening test for Down's syndrome?

The best screening test is arguably the one that provides the highest detection rate with the lowest false positive rate, thereby reducing to a minimum the number of women subjected to unnecessary diagnostic testing and the associated risk of miscarriage.

There is currently wide variation in the provision of Down's screening across the country.However, the recent NICE guideline on antenatal care has recommended that by 2007, all pregnant women should be offered one of three tests, all of which have a false positive rate of <3 per cent for a detection rate of 75 per cent. In the second trimester (14-20 weeks), women will be offered the quadruple test (serum measurement of C-hCG, AFP, uE3 and inhibin A).

In the first trimester (11-14 weeks), women will be offered the combined test (nuchal translucency measurement and serum measurement of free C-hCG and PAPP-A). The additional advantage of first trimester screening is that early diag-nosis and surgical termination of preg-nancy can be offered to women with affected pregnancies.

Current evidence suggests an integrated test combining serum screening and nuchal translucency measurement in the first trim-ester with further serum screening in the second trimester provides the best results (false positive rate of just 1.2 per cent for an 85 per cent detection rate). However, this higher detection rate comes at the cost of delaying until the second trimester. Full and thorough counselling is essential.

8. What is the point of screening for group B streptococcus in early pregnancy?

GBS is recognised as the most frequent cause of severe early-onset infection in newborns. In 2001, there were 376 cases of neonatal GBS in the UK, 39 of which were fatal. Many affected infants have recognised risk factors such as prematurity, a history of prolonged rupture of the membranes, fever in labour, or a previously affected older sibling.Bacteriological screening programmes in the US have resulted in 27 per cent of women being offered intra-partum antibiotic prophylaxis.

Studies have suggested there has been a reduction in the incidence of neonatal GBS but have not demonstrated an effect on neonatal mortality. About 25 per cent of pregnant women in the UK carry GBS and 15 per cent have one or more of the risk factors. Various screening methods have been advocated including vaginal swabs between 35-37 weeks or a risk factor approach, to identify women who would benefit from intrapartum antibiotics.

At present, there is insufficient evidence to advocate the introduction of screening. Bacteriological screening in early pregnancy is not advocated either. Oral antibiotics do not reduce the likelihood of GBS colonisation at the time of delivery and confer risks such as potentially fatal anaphylaxis and infection with resistant organisms.

9. Ginger is recommended as safe for the treatment of early pregnancy-related nausea and vomiting ­ how does this work? Is it fresh ginger or will powdered work? Is any particular product recommended?

Ginger is commonly used to treat nausea and vomiting of pregnancy. Ginger is thought to possess anticholinergic and anti-5-HT properties and thereby increases gastric tone and peristalsis. As it acts directly on the digestive tract, it avoids the CNS side-effects common to centrally acting antiemetics. As well as fresh and powdered, ginger is also available in capsule or syrup form.

Numerous recent placebo-controlled double-blind, randomised clinical studies have provided convincing evidence for the effec- tiveness of ginger in treating nausea and vomiting during pregnancy. These studies used a daily 1g dose in capsule or syrup form, from four days to three weeks, with no adverse outcomes or side-effects.

Ginger has a long history of safety and is classified by the FDA as 'generally recognised as safe'.

10. Are any complementary therapies established as being safe during pregnancy, particularly for analgesia?

Adequate evidence of benefit in reducing pain exists for a variety of therapies including continuous labour support, baths, intradermal water blocks, and maternal movement and positioning.

Acupuncture, massage, transcutaneous electrical nerve stimulation, and hypnosis are promising, but require further study. The effectiveness of education, relaxation and breathing, heat and cold, acupressure, hypnosis, aromatherapy, music and audio analgesia are either inadequately studied or findings too variable to draw conclusions.

However, all the methods listed are reported to be safe and to have evidence of widespread satisfaction.Louise Kenny is a consultant obstetrician and a researcher in the maternal and fetal health research unit at the University of Manchester - it is funded by Tommy's, the baby charityCompeting interests None declared

Dr Roy responds to the answers to her questions

I will now advise all my pregnant patients that ginger is a safe and effective treatment for nausea and vomiting during pregnancy, and can be taken in any form - I will amend the practice formulary to reflect the fact that paracetamol is safe on an occasional-use basis for analgesia during pregnancy, however it should not be taken every day

-I will also discuss the role of complementary therapies in pregnancy with my primary care team, to identify any local resources that might be available to patients

Dinah Roy is a GP in Sedgefield, Cleveland, and PEC chair of Sedgefield PCT

The role of GPs in newborn screening

Recent policy developments mean changes to the role of the GP in newborn screening as Dr Fred Kavalier, Dr Katrina Hargreaves, Dr Jennifer Sinclair, Dr Sandy Oliver and Ruth Stewart explain

Historically, GPs have had little direct involvement in the newborn blood spot screening programme. The heel-prick test is usually carried out by a midwife, while normal results - the vast majority - are generally recorded in the Personal Child Health Record and given to parents by health visitors. In practice, many GPs and parents never received the results of the newborn tests ­ they were simply assumed to be normal.

But recent policy developments are are changing this process and giving newborn screening a higher profile. In addition to screening for phenylketonuria (PKU) and congenital hypothyroid-ism (CHT), all babies are now offered screening for sickle cell disorders.

The Government has also announced plans to introduce screening for cystic fibrosis (CF) in England. And screening for medium chain acyl-COA dehydrogenase deficiency is being piloted.In addition there is now increased emphasis on informed consent and with the publication of new national policies and standards, it is important that GPs and other primary care team members are aware of their roles in the newborn screening process.

If a parent declines screening GPs and health visitors will be notified in writing of the conditions for which a baby has not been screened. This is to ensure that if the child becomes ill, GPs and health visitors know these tests have not been done. If parents change their minds, health visitors should arrange testing as soon as possible.

However, delayed testing may mean treatment starts after some irreversible damage has already occurred. GPs will receive normal results, which should be recorded in the Personal Child Health Record and the result given to the parents before or at the six-eight week check. It is important to note that a normal result means the condition has not been suspected; it does not mean it has been ruled out.

While the detection rate among babies tested for PKU and sickle cell disorders is very high, screening will not detect all children with CF, while CHT can develop after the screening test is carried out. This means babies presenting with symptoms suggestive of CF should be referred and tested even if it was not suspected from screening. The same goes for CHT.

Abnormal screening test results

GPs will be contacted if a baby in their care is suspected of having a condition, or found to be a genetic carrier of CF or a sickle cell disorder. They will be provided with relevant information and informed about what happens next. They will also be advised on any role they and other health professionals in their area may have in communicating the results to parents, and initiating referral. This may take the form of paediatric care or genetic counselling.

All parent decisions about screening, including consent or dissent, should be recorded in the mother's maternity notes. All results of the screening tests should be recorded in the Personal Child Health Record. If a child has not been screened, this fact should also be recorded in the Personal Child Health Record.Help for GPs

The UK Newborn Screening Programme Centre has developed a comprehensive pack of resources for health professionals, to provide them with up-to-date information and resources.This includes a range of evidence-based information leaflets for parents developed by the Parent Support Research Team of the UKNSPC: a pre-screening leaflet for expectant parents; results leaflets for parents of babies found to be affected by PKU, CHT or CF, or to be carriers of CF and accompanying communication guidelines.

The resource pack can be viewed and downloaded from the UKNSPC website (see right)

Fred Kavalier is a GP and primary care geneticist at Guy's Hospital, London - he is a member of the management board of the UK Newborn Screening Programme Centre

Ruth Stewart, Katrina Hargreaves, Jennifer Sinclair and Sandy Oliver are members of the Parent Support Research Team, UK Newborn Screening Programme Centre, based at the Social Science Research Unit, Institute of Education, University of London

Competing interests None declared

The UK Newborn Screening Programme Centre was established in 2002 with the objective of assuring high-quality screening services for babies and their parents. The programme centre is a collaboration between Great Ormond Street Hospital for Children NHS Trust, the Institute of Child Health (University College London) and the Institute of Education (University of London). It is funded by the Department of Health of England on behalf of all four UK countries.

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